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  • Subject Name : Nursing

PTA Therapeutic Techniques 2: Modalities and Physical Agents

Ans1. Keith is a sixteen-year-old boy and diagnosed with complex regional pain syndrome. Before that, he actively participated in various sports like downhill skiing, volleyball and basketball. Because of his physical health condition, he had stopped playing sports and limited his socializing time with his groups, as he felt embarrassed to not cope-up with them. Keith is trying to be cut off from society, in the long term that can lead to stress to him. Social exclusion and stress can be the two determinants that can affect his rehabilitation. A person who suffers from bad material and social living state can experience high level of stress. In the present case, there is potential that Keith might develop stress due to his no participation in sports. Chronic stress can cause prolong biological response that can strain the body. Continuous stress can lead to weak resistance system towards the illness by disturbing metabolic and hormonal systems functioning. Social exclusion has a tremendous impact on the health condition of the person. Social exclusion can generate a sense of hopelessness, depression and powerlessness. Social exclusion and stress can lead to chronic disease including cardiovascular and respiratory diseases and diabetes in adulthood, further, can lead to low body immunity to fight with other health conditions.

Ans 2) In clinical settings, it is vital to assess pain and manage it as per the need of the patient. There is three commonly deployed tool to assess pain intensity contain numeric, visual analogue and verbal rating scales. In the present case, along with a numerical scale, visual analog scale can be effective tool. FLACC scale can be deployed for pain assessment. FLACC is an assessment of sign associated with facial expression, legs position, body activity, crying (while awake or asleep) and controllability. This scale is for children or the adult who is not able to communicate. Based on the observation, zero to two grades assigned for all the included areas. The score can range from zero to ten. Score zero indicates that the patient is comfortable and relaxed. Score 1 to 3 is for mild discomfort, 4 to 6 is for moderate pain and 7 to 10 indicates severe pain. In the present case, Keith is very disturbed due to his painful ankle. For the same reason he has stopped playing in his school consequently he might feel depressed and sometimes will not communicate about his condition therefore visual analogue scale would be beneficial in his case to assess his pain intensity. 

Ans3) Heating pads and ice packs are common rehabilitation tool that can be used in the present case. Therapeutic contrasting is the process of making sudden change in the tissue temperature from hot to cold then back again. Contrasting is a cheap, simple, safe and effective technique for tissue injury recovery. In the present case scenario, contrasting can be started with 2 minutes of comfortably hot water followed by 1 minute of cool water (not cold), then again 2 minutes with little hotter water (bearable by the patient) followed by 1 minute of colder water. It is advisable to increase the temperature intensity gradually so that the patient can adapt to the temperature change. Contrasting contain a mild tissue workout- tissue stimulation without any stress and an ample amount of sensation without any movement, that might be beneficial for the injured tissue. It can be concluded that in the current case, it is vital to start with a comfortable hot temperature then end it with cold temperature. The intensity of the temperature should be gradually increased: that is the cold temperature gets colder and the hot temperature gets hotter.

Ans 4) Complex regional pain is a long long-term painful condition that causes constant, severe and burning pain in the leg and/or arm. In this condition, the nerves become hypersensitive further this condition arises due to infection, trauma, stroke and fracture. Cold weather and snowing can lead to unpleasant symptoms. In the current case, it is essential to guide the patient for the winter session, as the temperature will be below zero degrees. The patient must not step out from his/her house until and unless there is something urgent as a precaution is always better than cure. Keith needs to protect his leg from the chilling weather, for the same he can wear warm fuzzy socks along with the furry boots. Furry boots and warm shocks can be comfortable and help in temperature maintenance while Keith will go out. Further, various foot warmers are available in the market so the patient can buy that. It is advisable to wrap up properly with warm gloves, scarves and hat while footing outside the home in the cold weather. Moreover, the patient can have Epsom salt baths as it helps in soothing pain. It can be concluded that Keith needs to be well wrap up him while stepping out of his home.

Ans 5) Long-arc quad workout is for strengthening the quad muscles. In this workout, the patient needs to sit straight in the chair and lift his/her leg then straighten leg. Further, the patient need not lock the knee, hold the leg in the straightened position for the count to five. In the current case scenario, Keith is not able to tolerate weight around his ankle due to sensitivity to touch. Therefore, it is necessary to start with easy and simple workout without any weight. Initially, Keith can start with bodyweight leg extension workout. This workout will help him to make quads muscles stronger. Further, Keith can do standing leg extension exercise as this will helps him to strengthen his quads and core muscles. Moreover, this workout will help him to build coordination and body balance. The squats will also beneficial for him to target his quads muscles. Further, step-ups are a simple and effective way to strengthen glutes, hip and quads. If Keith will able to perform the above-stated exercise then little weight can be put around the ankle and gradually the weight can be increase and adjust as per his physical condition.

Ans 6) Acupuncture treatment can reduce or replace the drug dosage like morphine, taxane to reduce the adverse effects associated with the prescribed drugs to manage and treat chronic pain. In the current case, Keith was undergoing through acupuncture therapy and during the process, he had complained that he was feeling like to pass out. Fainting is the common side effect associated with an Acupuncture therapy that contains symptoms like perspiration, syncope and dizziness. By evaluating the case, it might be possible that Keith would develop syncope. The physiotherapist must ready for such situation as fainting is sudden and brief conscious loss condition. In such a condition, the health care worker should be calm and make the patient take the proper position. The head of the patient should be below the heart level with elevated legs as this position ensures proper blood flow towards the brain. It is always advisable to call for assistance but never leaves the patient alone. After the proper position, the health care worker must check for pulse and breath. It is vital to start rescue breathing if there is no breathing sound. The health care worker must check for tight fitted clothing, especially around the neck. Further, the physiotherapist can apply firm pressure on stomach 36 and Governing Vessel 26 to revive from syncope.

Ans 7) Complex regional pain is the condition which is treated through collaboration amongst physiatrists, rehabilitation professionals and surgeons. Rehabilitation team consists of an occupational therapist and a physical therapist. Occupational therapists are responsible for presenting and sustaining stress loading sessions for CRPS patients. Such sessions consist of distraction exercises and active compression, which render impulse to the affected body part without any joint movement. Occupational therapists and physical therapists when works as a team, can resultant in a tremendous improvement in CPRS patient. Occupational therapists contribute to reestablishing and maintaining autonomy. In many cases, due to collaboration, the patient's ability to roam around his/her home has been improved. Therefore, the patient has gained a sense of self-dependency and aids in improving mental health too. it can be concluded that occupational therapist will aid in pain management, restoring psychological element and functional restoration with collaboration amongst different disciplines.

Ans 8)

a) In the present case, the physiotherapist had tried TENS at 2 HZ. TENS can be given at three settings- 80 to 129 HZ, 35 to 50 HZ and 2 to 10 HZ. With 80 to 129 HZ, acute pain can be relieved. For chronic pain, 2 to 10 HZ frequency is beneficial. 35 to 50 HZ is for muscle stimulation. Keith will get relief in chronic pain with TENS at low frequency (2HZ).

b) Transcutaneous Electrical Nerve Stimulation (TENS) - is a little electrical device with stickable small pads, which can be attached or stick on the outer surface of the body. This device will generate some impulse to reduce the pain intensity by cutting the pain signal pathway from the affected body part to the brain. It is a non-invasive non-pharmacological method aids in reducing pain. You may feel buzzing and/or tingling sensation on your affected area when the pads where placed on the skin.

c) In the TENS unit, self-adhesive pads are electrodes. The electrodes usually placed over the perimeter of the zone that needs to be treated. This permit the electrical current to flow through the nerves within the painful zone. For pain in the ankle region, two electrodes can be placed in the ankle region and electrodes should be placed around the severe pain point. It is advisable to no to place pads directly on the joint as the movement of joint can displayed it easily. Moreover, never placed adhesive electrodes near or on the heart region as it can leads to disturbance in heart rhythm due to the electric current produced by TENS unit.

d) Keith needs to use TENS at his home. For the same, he can opt for the rental TENS machine. The contact details are as follow:

Contact number: (416) 901-3509, 905-532-9494

Address: Toronto Store, 3537 Bathurst St. Toronto, ON M6A 2C7

Timing: Mon-Fri 9am-5pm | Sat 10am-2pm | Sun Closed

Store name: Vital Mobility Home Health Care

 Ans 9) The SOAP (stands for subjective, objective, assessment and plan) is the technique to document the present condition of the patient. Subjective section of the report aims to state the chief complaint of the patient followed by a brief history of the present illness. Objective section is about measuring and reporting the vital signs and physical examination results of the patient. Further, Assessment component addresses the etiology, risk factors, current therapy, assessment of the therapy and other therapy options. Plan section includes future treatment modality of the patient. Keith is undergoing through the physiotherapy session from last 8 days. The given below table will illustrate the changes that had occurred from day 1 to till date.

Table1: Physical condition changes


Pain rating




Weight bear




Decreased ,active ankle dorsiflexion=0⁰ left ankle=15⁰ ankle plantar flexion=30⁰ ,left side=60⁰

Minimal, Water displacement right leg=35ml more than the left side


ankle movements MMT of 3/5

knee flexion and extension MMT of 4/5

Right ankle=no

climb and step down 1 flights stairs with railing and crutches



Dorsiflexion =10⁰ plantarflex=50⁰. 



partial weight-bearing

climb and step down 2 flights individually

Table 2: Documentation of the session of 8th day using the SOAP format

Current condition

complex regional pain syndrome (CRPS), Site- Right ankle 


Long term goal- Decrease pain, restore the function of right leg and ankle, maintain life quality and participation in sports again.

Short term goals- attain pain score 5/10, Dorsiflexion =12⁰ plantarflex=52⁰, climb and step down 4 flights individually,


The patient is happy as he is doing well


On evaluation, the pain rating is 7/10, the patient can move his right ankle with plantarflex 50⁰ and Dorsiflex by 10⁰

The patient had achieved normal gait X70 m while having partial weight on right ankle.

Climb and step down 2 flights individually.


The patient continues to present with complex regional pain syndrome, having moderate pain with little swelling.


Continuation of the current workout plan with a gradual increase in weight on the right ankle, continue with the TENS therapy; attempt climbing and stepping down individually again tomorrow

Ans 10)

a) In the present case, Keith is a 16-year Canadian male and I am 23 years old Indian female. We both are from a very different culture. Being a female, it is difficult to talk about sports. However, effective communication including verbal and non-verbal will make it easy to approach Keith. The physiotherapist has added contact time with the client as compared to other team members. This implies that they have an appropriate place to develop a deeper relationship with the patient. Canada has a multicultural society system therefore; our culture will not create any gap. Moreover, we both are of almost the same group, there might be the possibility that Keith will allow to discuss the sensitive topic. I will ask Keith about his thought about sports. By asking this, I am seeking permission from the client to talk over on the issue.

b) Healthcare workers need to deliver optimal and holistic care to the patient, but along with that, it is vital to screen for the psychosocial threat to the patient in the healthcare sets. In the present case scenario, Keith had stopped talking about sports to the therapist therefore this raises the alarming situation. To talk about such a sensitive topic, the physiotherapist needs to change his/her attitude and way of communication. A physiotherapist has a unique position in the multidisciplinary team therefore they should have important communication skill. The physiotherapist has added contact time with the client as compared to other team members. This implies that they have an appropriate place to develop a deeper relationship with the patient. In the case of Keith, it is essential to approach him calmly without showing any fear. The physiotherapist can deploy both verbal and non-verbal way of communication. Further, good listening and assessing the patient’s situation can be proven effective. The physiotherapist asks Keith about his thought towards sports. By asking this, the physiotherapist will seek permission from the client to talk over on the issue. Deploying communication approach will permit the physiotherapist to express empathy and respect to the client.

c) Keith's behaviour including showing little emotions and had not changed his clothes or not washed his hair, showing that he is in depression. The physiotherapist has a deeper relationship with their client therefore, it is expected from them that they should be aware of the patient's symptoms and signs of depression. After evaluation of the patient's behaviour, the therapist should notify the concerned physician to make a proper treatment plan for the patient. A client with depression symptoms might be emotionally not stable therefore recognizing his/her situation is vital to redirect the client towards additional activities and conversation related to positive topics.

In the present case, exercise can be an effective method to help the patient to come out from his depression. Exercise is beneficial in depression, anxiety and mood disorder’s patients. Aerobic exercise induces pituitary gland to secrete endorphins, which are pain relievers and mood enhancer. Further, endorphins aids in lowering cortisol levels, usually increased cortisol levels are associated with depression. Moreover, exercise improves serotonin sensitivity in the same manner as antidepressants work. Both aerobic and resistive exercise seems to be beneficial in the present case. Depression signs can be decreased by exercise session although the results are not permanent. Daily exercise can help in improving self-esteem also. Cognitive-behavioural Therapy is the other technique that can be deployed to manage depression and anxiety. The therapist can work to break the negative thought cycle. Negative thought cycle includes negative thought followed by negative feelings than bad health condition; break in any of the above-stated levels can help the patient to come out from depression. Communication is the key method to deliver positive thoughts to the client. It can be concluded that proper communication, exercise and Cognitive-behavioural Therapy could be effective in the current case.

Ans 11) Invitation from the client and their family may be looks appealing but it is vital to look for the ethical issues. Keith's family had invited for lunch, but this scenario had created an ethical dilemma. The health care workers should not use their position to a purse or establish an emotional relationship with their patient and patient's family. Before accepting the invitation, the health care worker should ask one question from himself or herself that what would be the consequences to accept the invitation from the client. It is not wrong to decline the invitation to protect the doctor-patient relationship.

Remember, at the center of any academic work, lies clarity and evidence. Should you need further assistance, do look up to our Nursing Assignment Help

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